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Table 4.
Medical Necessity Provisionsin Medicaid Managed Care Contracts
California
Other diagnosis and treatment 
Diagnosis and treatment of any medical conditions identified throughany CHDP assessment will normally be initiated within sixty days of the CHDP assessment appointment, consistent with the terms of theContract for the identified services or conditions. Justification fordelays beyond sixty days will be maintained in the Medical Record.
California Contract
, page 96.
6.7.4.4
 
EARLY AND PERIODIC SCREENING, DIAGNOSISAND TREATMENT (EPSDT), SUPPLEMENTALSERVICES, INCLUDING CASE MANAGEMENTSERVICES
For member under the age of 21 years, the Contractor will provide orarrange and pay for EPSDT supplemental services as defined in Title22, CCR, Section 51184, excluding EPSDT case managementservices, except when EPSDT supplemental services are provided asCCS services pursuant to Section 6.7.3.2.Follow prior authorization and utilization review criteria established bythe Department for fee-for-service beneficiaries for EPSDTsupplemental services, including EPSDT case management services.The Department expects to have more detailed information on theEPSDT supplemental services, especially on EPSDT casemanagement serves during the contract implementation period.
California RFP
, page 91. The Contractor will determine the medicalnecessity of EPSDT supplemental services using the criteriaestablished in Title 22, CCR, Section 51340.
California Contract
,page 91.
9.7.4.2.
The applicant will describe procedures for identifyingneeded EPSDT supplemental services, including EPSDT casemanagement services, and for ensuring that the necessary servicesare provided.
California RFP
, Section 9.7, page 14.
Pediatric medical necessity standard 
EPSDT Supplemental Services, including case managementservice…EPSDT supplemental services are defined in Title 22, CCRSection 51184 and include medically necessary health services thatwould not otherwise be covered by the Medi-Cal program….”
California Contract
, pages 91-92
 Delaware
Other diagnosis and treatment 
6.1.1.3 Diagnosis and Treatment
If a suspected problem is detected during a screening examination,the child must be evaluated as necessary for further diagnosis. Thisdiagnosis is used to determine treatment needs.EPSDT requires coverage for all follow-up diagnostic and treatmentservices deemed medically necessary to ameliorate or correct aproblem discovered during an EPSDT screen. Such medicallynecessary diagnosis and treatment services must be provided as long
 
as they are Medicaid-covered services as defined in Delaware RFP,Appendix F.
Delaware RFP
, pages II.25- II.26.
Pediatric medical necessity standard 
6.1.1.3 Diagnosis and Treatment
EPSDT requires coverage for all follow-up diagnostic and treatmentservices deemed medically necessary to ameliorate or correct aproblem discovered during an EPSDT screen. Such medicallynecessary diagnosis and treatment services must be provided as longas they are Medicaid-covered services as defined in Delaware RFP,Appendix F.
Delaware RFP
, pages II.25- II.26.
 District of Columbia
Other diagnosis and treatment 
1.
 
Covered Servicesa.This contract provides for coverage and provision byProvider of all medical assistance benefits and services that arelisted in Attachment I, which is incorporated herein as part of thiscontract:2.Early and Periodic Screening Diagnosis and TreatmentServices (EPSDT) for Enrollees Under 21 Years of Agea.
 
The EPSDT program is the pediatric component of Medicaid and requires coverage of periodic andinterperiodic screens, vision, dental, and hearingcare, diagnostic services needed to confirm theexistence of a physical or mental illness or conditionand all medical assistance services that arerecognized under Section 1905 of the SocialSecurity Act, even if not offered under the stateplan to persons age 2 and older. In operating theEPSDT program, Provider shall be bound by allfederal laws applicable to the program (including 42U.S.C. §§1396d(a)(43), 1369d(a)(4)(B), and1369d(r).(5)
 
Provider shall be responsible for coverage and provisionof all services required to diagnose a condition other thanmental illness or addiction disorder diagnostic services. In thecase of services required to diagnose a mental health conditionin an individual under age 21, Provider shall arrange for suchdiagnostic services but is not responsible for the cost of providing such diagnostic services.
Pediatric medical necessity standard 
H. Coverage and Benefits
2.
 
Early and Periodic Screening Diagnosis and TreatmentServices (EPSDT) for Enrollees Under 21 Years of Age
 
Table 4.
Medical Necessity Provisionsin Medicaid Managed Care Contracts
(10)
 
In making medical necessity-related coveragedeterminations in the case of children under 21,Provider must authorize coverage if, taking intoaccount the clinical evidence, as well as therecommendations of the child’s PCP and other health,educational and social service professionals caring forthe child, Provider determines that a service coveredunder this contract is necessary to:(a)
 
correct or ameliorate a physical or mentalcondition; or(b)
 
prevent the onset or worsening of a disabling orchronic condition.6.
 
Services for Children with Developmental Disabilitiesa.
 
Provider is responsible for coverage and provisionof services other than services necessary for thediagnosis and treatment of mental illness andaddiction disorders in the case of children withdevelopmental disabilities, as defined in ArticleXXII.b.
 
In making coverage determinations in the case of children with developmental disabilities, Providershall provide coverage if, taking into considerationthe clinical evidence as well as the opinion of health,educational and social service professionalsfurnishing care to such children, Providerdetermines that the care is necessary to correct orameliorate the effects of a developmental disability.
District of Columbia Contract
, pages 21, 22,24-26.
 Hawaii
Other diagnosis and treatment 
30.730 Children’s Medical and Behavioral Health Services(EPSDT Services)
* Screening and medically necessary diagnosis and treatment of conditions detected as a result of EPSDT screenings (completeperiodic interperiodic, or partial); include but are not limited totimely...tuberculosis screening...diagnosis and treatment of acute andchronic medical, behavioral health conditions.-When screening examinations indicate the presence of a medical...or behavioral health condition, the health plans must provide medicallynecessary medical and behavioral health treatment...With theexception of the services provided by the Department of Health, thehealth plans shall be responsible for providing all services listed in30.710 Medical Services and 30.720 Behavioral Health Services tochildren under EPSDT. Children are not subject to the behavioralhealth limits.Additionally, children may receive other and additional medicalservices determined as medically necessary to correct or amelioratedefects of physical illnesses and condition discovered as a result of EPSDT screens. Prescription drugs not on the health plan’s
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